BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK, NY 10573 (914) 939-0668 www.ryebrook.org

PLUMBING PERMIT APPLICATION

FOR OFFICE USE ONLY BP #: _______________________ PP #: _________________________ Approval Date: ____________________________________ Permit Fee: $ ___________________________

Approval Signature: ________________________________ Other: ________________________________

Disapproved: ______________________________________ (fees are non-refundable)

************************************************************************************************** Application dated, _________________is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below. The applicant & property owner, by signing this document agree that said plumbing work will be in conformance with all applicable Federal, State, County and Local Codes. 1. Address: _______________________________________________________SBL: _________________________ Zone: ________

2. Proposed Work: _____________________________________________________________________________________________

_________________________________________________________________________________________________________

3. Property Owner: ______________________________________ Address: ______________________________________________

Phone #: ___________________________ Cell #: __________________________email: __________________________________

4. Master Plumber: ______________________________________ Address: _______________________________________________

Lic. #: ________ Phone #: ___________________ Cell #: ____________________ email: _________________________________

Company Name: ______________________________________ Address: ______________________________________________

INDICATE FIXTURES & LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE:

Location Water Closets

Urinals Drinking Fountains

Sinks

Showers Bath Tubs

Laundry Tubs

Domestic Service

Fire Service

Sanitary Sewer

Natural/ LP Gas

Other* Total

Basement

1st Floor

2nd Floor

3rd Floor

4th Floor

5th Floor

Exterior

5. * List Other Equipment/Provide Details: _________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

(Notarized Signatures Required Next 2 Pages)

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STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as:

_________________________________, being duly sworn, deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant)

and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the

_________________________________________ for the legal owner and is duly authorized to make and file this application.

(indicate architect, contractor, agent, attorney, etc.)

That all statements contained herein are true to the best of his/her knowledge and belief, and that any work performed, or use

conducted at the above captioned property will be in conformance with the details as set forth and contained in this application

and in any accompanying approved plans and specifications, as well as in accordance with the New York State Uniform Fire

Prevention & Building Code, the Code of the Village of Rye Brook and all other applicable laws, ordinances and regulations.

Sworn to before me this ______________ Sworn to before me this ______________

day of _________________, 20________ day of _________________, 20________

__________________________________ __________________________________ Signature of Property Owner Signature of Applicant

__________________________________ __________________________________ Print Name of Property Owner Print Name of Applicant

__________________________________ __________________________________ Notary Public Notary Public

This application must be properly completed in its entirety and must include the notarized signature(s) of

the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Applications

not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be

returned to the applicant.

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BUILDING DEPARTMENT

VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK, NY 10573

(914) 939-0668 www.ryebrook.org

*******************************************************************************************************

AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS

THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED

ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT.

STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as:

I, __________________________________, residing at, ____________________________________________ (Print name) (Address where you live) being duly sworn, deposes and states that (s)he is the applicant above named, and further states that (s)he is the

legal owner of the property to which this Affidavit of Compliance pertains at;

___________________________________________________________________________, Rye Brook, NY. (Job Address)

Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes.

______________________________________________________________________ (Signature of Property Owner(s)) _________________________________ _____________________________________ (Print Name of Property Owner(s)) Sworn to before me this _______________

day of ___________________, 20_______ ___________________________________ (Notary Public)

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